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SIGN provides best practice advice on care of obesity

Dr Matt Capehorn reiterates the importance of primary care in the prevention and management of the obesity epidemic

In February 2010 the Scottish Intercollegiate Guidelines Network (SIGN) published its guideline on Management of obesity.1 This has been the first major review of all available evidence since the National Institute for Health and Care Excellence (NICE) published a comprehensive obesity guideline in 2006.2 Since this document, there have been very few consensus guidelines or updates to reflect recent changes in practice. Is the new SIGN guideline a welcome addition?

One main focus of the SIGN guideline was the review of best practice based on the current available evidence, taking cost effectiveness out of the equation. There is an obvious argument for having a review that only examines what clinical management should involve and provide if cost is not an issue. A further welcome addition in the guideline is the incorporation of ‘good practice points’ that reflect the consensus opinion of specialists in this field—when current practice suggests a clear management option, but there is no evidence to support it.1 In this way the guideline serves to be both a reference point for current evidence and also a consensus guideline on best practice when the evidence is lacking. This provides the practitioner with much more practical help than a simple literature review.

It is reassuring to find that 4 years after the publication of the NICE guideline, the new SIGN guideline reinforces most of the same advice that appeared in it.1,2 There is once again clear and referenced advice on the key areas such as classification of weight using body mass index (BMI) and waist circumference, prevention, identification, assessment, and treatment in both adults and children.1 However, there are some areas worthy of note and clarification to avoid potential confusion among practitioners and these are discussed below.

Assessment of obesity in children

It is important to highlight the fact that during assessment of obesity in children, the classification of overweight/obese has been based on the 91st/98th BMI centiles, respectively.3 There is in fact at least some evidence to support this, which is given in the guideline,1 and this criteria has been used by the Royal College of Paediatrics and Child Health for some time. However, it has now been rendered unhelpful south of the Scottish border since the advent of the National Child Measurement Programme for England, in which the Department of Health (DH) insists on using the arbitrary 85th/95th classification.4

In practice it would have been better for the DH to have adopted the 91st/98th BMI centile criteria, especially as these are clearly marked on the child growth charts that all clinicians should be encouraged to use. However, I imagine that this classification is now too established to be altered, and is here to stay. This could obviously lead to confusion among patients and healthcare professionals, and there are issues relating to the compatibility of data if patients are accessing healthcare services in a different country within the UK.

Managing obesity and co-morbidities

One further point of note in the new SIGN guideline is with respect to the treatment of patients with a BMI >35 kg/m2. There is an assumption that patients with a BMI >35 kg/m2 are likely to have obesity related
co-morbidities and that the focus of weight-loss interventions should be aimed at improving these
co-morbidities,1 with the implication that we should not just be reducing actual weight for the sake of it. This may be considered a welcome opinion as there has been long debate over how ‘simple obesity’, in the absence of
co-morbidities, should be managed, and whether the same time and resources should be apportioned to this group of patients. However, how will this advice be interpreted?

For those GPs keen to manage obesity, they will see this as an opportunity to manage patients more aggressively if their BMI >35 kg/m2 (aiming for the recommended 15%–20% or over 10 kg weight loss),1 assuming that
co-morbidities are present, even when currently not yet diagnosed. However those practitioners who have never been keen on managing obesity may interpret this advice as an opportunity not to offer any weight management services to a patient with a BMI >35 kg/m2 if they have no proven co-morbidity, with the obvious potential argument that it then becomes no different to a cosmetic procedure. This would be extremely short-sighted on a number of levels, and I hope this scenario never arises.

Bariatric surgery

The SIGN recommendation on when bariatric surgery should be considered in adults is much more concise and workable than in the NICE guideline. The SIGN guideline advises the consideration of bariatric surgery after individual assessment of risk/benefit in patients with a BMI >35 kg/m2 and one or more severe
co-morbidities, and evidence of having completed other interventions as part of a structured weight-management programme.1

There is no additional, higher BMI criteria for consideration in the absence of
co-morbidities, such as BMI >40 kg/m2
as recommended by NICE.2 However, given the ridiculous situation that we have at present, where primary care trusts in England do not have to offer surgery despite the NICE guideline recommending it as a possible treatment, will a similar thing happen in Scotland?

Supporting obesity management

Perhaps my only criticism would be that the SIGN guideline has not been explicit enough in advising our profession that obesity is a serious medical condition and everyone’s responsibility. I appreciate that many GPs may feel that they do not have the time, staff, resources, knowledge, or inclination to manage obesity; and service provision from those practitioners who do manage this condition can vary considerably. Perhaps this is the best argument, for obesity services to be provided at a practice-based, locally enhanced service, or region-wide commissioning level. There are now established models for fully integrated obesity services that include a specialist multidisciplinary approach in primary care.5

Conclusion

Overall I think it is quite clear that the recommendations in the SIGN guideline are both helpful and a useful addition to existing guidelines (e.g. NICE and National Obesity Forum guidance).2,6

However, it is vital that we stress at every opportunity that the success of any weight-management programme relies on healthcare professionals identifying and appropriately referring patients who are overweight and obese to the services available. It should now be our focus to encourage colleagues to use brief interventions during the consultation, to raise the topic of weight, and take the opportunity to weigh and measure patients. Given the fact that nearly two out of three adults and nearly one out of three children are overweight, GPs cannot deny that they are seeing these patients on a daily basis.7

National Institute for Health and Care Excellence. Obesity: Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline 43. London: NICE, 2006. Available at: www.nice.org.uk/guidance/CG43